Congestive heart failure Pharmacological treatments for patients with heart failure with reduced ejection fraction

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Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]

Overview

The major goals of pharmacologic treatment for patients with HFrEF are reducing mortality, reducing the risk of repeated hospitalizations due to worsening HF, and improving clinical status, functional capacity, and quality of life. The mainstay of treatment for HFrEF is the modulation of the [[renin-angiotensin-aldosterone] system] (RAAS) and sympathetic nervous system.

Therapuetic approach

• The major goals of pharmacologic treatment for patients with HFrEF are:
  • 1) Reducing mortality (either all-cause or cardiovascular)
  • 2) Reducing the risk of repeated hospitalizations due to worsening HF
  • 3) Improving clinical status, functional capacity, and quality of life
• The cornerstone of pharmacologic management of HFrEF is the modulation of the [[renin-angiotensin-aldosterone] system] (RAAS) and sympathetic nervous system (i.e., neurohormonal blockade).

For all patients: To reduce mortality

Angiotensin-converting enzyme inhibitors (ACE-I) or an angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) reduce mortality, reduce the risk of repeated HF hospitalizations, and improve symptoms in patients with HFrEF. Thus, a combination of an ACE-I/ARNI, a beta-blocker, and an MRA is recommended as class I therapies for all HFrEF patients unless they are contraindicated or not tolerated. These drugs should be uptitrated to the doses used in the clinical trials or to maximally tolerated doses. Unless contraindicated or not tolerated, the sodium-glucose co-transporter 2 (SGLT2) inhibitors (dapagliflozin and empagliflozin) are also recommended for all HFrEF patients and should be added to pharmacotherapy of HFrEF patients that are already taking an ACE-I/ARNI, a beta-blocker, and an MRA, regardless of diabetes status.

For all patients

ACE-I/ARNI

BB

SGLT2i

MRA